1326 - Chorea of Unclear Etiology in a Multimorbid Elderly Patient: A Case Report

Friday, February 23, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

SG

Simron Gill, MD

Resident Physician
SUNY Downstate Health Sciences Center
New york, New York, United States

Co-Author(s)

RE

Ricki Ehrenfeld, BS

Medical Student
Touro University College of Medicine
Brooklyn, New York, United States
LC

Lawrence Andrew L. Chan, DO

Clinical Assistant Professor
SUNY Downstate Health Sciences University
Brooklyn, New York, United States
Sanjeev Agarwal, MD

Chief of Service & Residency Program Director
SUNY Downstate Health Sciences University
Brooklyn, New York, United States

Case Diagnosis: Chorea of unclear etiology

Case Description: A 68-year-old woman known for COPD, end-stage renal disease on dialysis, hypertension, recent Parkinson's disease diagnosis (5 months prior), and a history of stroke with residual left-sided deficits presented with post-dialysis shortness of breath. Respiratory distress prompted non-invasive positive pressure ventilation, and the admission diagnosis was COPD exacerbation. On assessment, a questionable essential tremor was noted, leading to the suspension of her home Sinemet. While her respiratory status improved during the hospital stay, she suddenly developed irregular and involuntary movements, particularly in her right upper extremity. MRI revealed an acute right frontal lobe infarct, with remote infarcts in the right pons and right caudate head. EEG results were normal. Secondary stroke prevention measures and physical therapy were initiated, requiring substantial assistance for ambulation and activities of daily living (ADLs). Treatment with benzodiazepines and risperidone yielded partial improvement. She was discharged to a subacute rehabilitation facility with a prescription for tetrabenazine.

Discussions: Chorea is a movement disorder characterized by sudden, involuntary, and jerky movements affecting limbs and facial muscles. It typically results from excess dopamine activity in the basal ganglia. While Huntington's disease is a well-known cause, chorea can arise from autoimmune diseases, brain injury, metabolic disorders, and certain medications. Notably, Sinemet, a levodopa and carbidopa combination, can induce chorea. These movements significantly impact mobility and daily life, necessitating adjustments to improve functional capacity. Treatment options include atypical antipsychotics, dopamine-depleting agents, and GABAergic medications.

Conclusions: When encountering acute hyperkinetic movement disorders, distinguishing between idiopathic, hereditary, or acquired causes is crucial. A thorough history and workup are necessary to identify reversible or hereditary factors contributing to chorea. Physical and occupational therapy play a vital role in maintaining functionality, complementing medication therapies aimed at mitigating choreic movements.